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ATSI CHILD HEALTH ASSESSMENT AGE
0-14YRS ITEM 715
Patient’s Name: <PtFirstName>
Sex: <PtSex>
Current Contact Details
Phone: <PtPhoneH>
Address:<PtAddress>
DOB: <PtDoB>
Age: <PtAge>
(Please tick box)
Aboriginal  Torres Strait Islander 
Aboriginal and Torres Strait Islander 
Mother’s Name:
Mother’s DOB:
Patient Consent/Parent or Carer consent
 Explanation of health check given
 Patient/ parent/carer consent for health
check
Date consent was given:
Would you like a written copy of the health
check and recommendations for you and
your child?
 Yes  No
Previous Health Check
Has the patient had a previous health
check?
 Yes
 No
Date of last health check (if known)
(must be more than 9 months ago)
Alternative Contact Details
Phone:
Address:
Consent given for information to be
collected by
 GP
 Practice Nurse
 Health Worker
 Other please specify
Details of GP conducting this health check:
MEDICAL HISTORY
CURRENT HEALTH PROBLEMS/ ISSUES
PAST MEDICAL HISTORY, HOSPITALISATIONS AND INJURIES
<PMHAll>
ALLERGIES/ DRUG INTOLERANCES
<Reactions>
CURRENT MEDICATIONS (including prescription and over the counter )
<CurrentRx>
RELEVANT FAMILY MEDICAL HISTORY
<FamilyHx>
IMMUNISATION STATUS Check Blue Book (or if details unavailable and child less than 7 years
can check with ACIR) Note: Catch-up Calculator - http://www.health.sa.gov.au/immunisationcalculator
Age due
Birth
2 months
4 months
6 months
12 months
18 months
2 years
4 years
Year 8 at
school
SA Immunisation Schedule for ATSI children
 Hep B
 Hib/Hep B  Prevenar  Infanrix/IPV
 Hib/Hep B  Prevenar  Infanrix/IPV
 Prevenar
 Infanrix/IPV
 Hib/Hep B  MMR
 Men C
 Varicella
 Hep A
 Pneumovax 23
 Hep A
 MMR
 Infanrix/IPV
 Boostrix (dTpa)
 Varicella (if not given before or no history of chicken pox)
 Hep B (if dod not receive primary course)
Other immunisations
Type
Date received
Date
ANY CONCERNS ABOUT HEARING?
HISTORY OF NEONATAL SCREEN?
HISTORY OF OTHER SCREENING?
ANY CONCERNS ABOUT VISION?
PHYSICAL ACTIVITY- Detail
Any Concerns?
NUTRITION
Any Concerns?
EDUCATIONAL PROGRESS
Any Concerns?
DEVELOPMENT
Any concerns identified by parent /carer / teacher / child?
 No
 Yes, Details:
RELEVANT SOCIAL HISTORY/ HOUSING
Who does the child live with?
Who is the primary carer of the child?
What is the current housing situation?
How many people live in the house?
Any concerns of overcrowding?
Does anyone in the household smoke?
If so, do they want assistance to quit?
Does the mother/ primary carer need help or support with alcohol, gambling, cigarettes, drug use?
STRESSFUL LIFE EVENTS:
HISTORY RELEVANT TO SPECIFIC AGE GROUPS
INFANT
RELEVANT
NOTES:
(Write N/A if not relevant)
Mother’s pregnancy
Any complications during
pregnancy?
Where did you attend
antenatal care?
Any issues with the
health care?
Birth and neonatal period
Mode of Delivery
Gestation
Birth weight
Any complications during
or shortly after the
delivery?
Breast feeding/ Bottle
feeding
Weaning, food access
and dietary history
Any questions or
concerns?
Physical activity
(details)
Vision and hearing
(including neonatal
hearing screening)
Development
(achievement of
age-appropriate
milestones)
Assess risk factors for
SIDS Provide education
Do you have any
concerns about your
infant?
Review of Blue Book
Any issues not covered?
Mother’s/ primary carer’s
current well being
(support network,
stressors/mood, general
health, DV)
History of Newborn
Check?
Dietary details of typical day
Personal-Social (e.g. smile, plays, indicates wants)
Concerns?  Yes
 No
Fine Motor- Adaptive (e.g. grasps rattle, pincer grasp, tower of cubes)
Concerns?  Yes
 No
Language (e.g.. Laughs, turns to voice, speech, words)
Concerns?  Yes
 No
Gross Motor (e.g.. Rolls over, sits, stands, walks, jumps, balance)
Concerns?  Yes
 No
 Yes
 No/uncertain
If less than 2 years old and no/uncertain, for full newborn examination.
CHILD IN ADOLESCENT STAGE
(eg. age 12-14)
ALCOHOL (if applicable)
Identified issues
Action
SMOKING/ TOBACCO (if applicable)
Identified issues
Action
OTHER SUBSTANCE USE (if applicable)
Identified issues
Action
Ask about mood, depression/anxiety, self-harm and general well-being
Identified issues
Action
SEXUAL AND REPRODUCTIVE HEALTH (if applicable)
Sexually Active?
Risk of STIs?
Contraception?
Identified issues
Action
OTHER HISTORY CONSIDERED NECESSARY
LIVING CONDITIONS AND EXPOSURE TO ENVIRONMENTAL FACTORS
Physical Activity
Nutrition
MEDICAL EXAMINATION
WEIGHT:
kg (
%ile)
Identified issues
HEIGHT:
cm (
%ile)
BMI 
Action
VISUAL ACUITY (red reflex in newborn)
Left:
Right:
 Normal
 Abnormal
Bilateral:
Identified issues
EAR AND HEARING:
Otoscopy  Normal
Action
 Abnormal
Whisper test  Normal
 Abnormal
Referral for Tympanometry and Audiology?  Yes
 No
Identified issues
Action
GUMS AND DENTITION
 Normal 
Abnormal
(Dental hygiene and access to dental services)
Identified issues
SKIN
Action
 (skin sores etc)
Identified issues
Action
New Born Baby Check – if not previously completed
Identified issues
Action
CARDIAC AUSCULTATION (consider congenital heart disease/rheumatic heart disease)
abnormality detected  Abnormal
Identified issues
RESPIRATORY EXAMINATION  No abnormality detected
Identified issues
ABDOMINAL EXAMINATION
 No abnormality detected
 Abnormal
TRICHIASIS
 Trachoma check if indicated
Action
 Abnormal
Action
 No
Identified issues
Action
ASSESSMENT OF PARENT CHILD INTERACTION
Identified issues
Action
OBSERVED INTERACTION BETWEEN PARENT/CARER AND CHILD (if indicated)
OTHER EXAMINATIONS CONSIDERED NECESSARY BY GP
Examination
Identified problems
INVESTIGATIONS AS REQUIRED
Investigation
Arrange FBC testing for
children at high risk of
anaemia
Arrange urinalysis
Audiometry
conducted when required
and at, or just before, school
entry?
BSL ?
Tests done
Tests ordered
Date:
Arrangements (e.g. referral details)
Date:
Date:
Date:
Date:
Date:
SUMMARY ASSESSMENT OF PATIENT
(based on consideration of evidence from patient history, examination and results of any investigation)
EXISTING HEALTH PROBLEMS or
IDENTIFIED ISSUES
ARE ANY OF THESE INTERVENTIONS REQUIRED?
Treatment
Follow-up
Immunisation
Referral
Medical
INTERVENTION ACTION/
RECOMMENDATIONS
Yes,
Today
Yes, organised
for when?
No / Not
necessary
Dental
Home visiting program referral
Family-focused intervention
Liaison with
the patient's school and
other service provider
Advice on:
Physical activity/ Exercise
Diet and nutrition
Parenting
Sun protection
Injury prevention
Infant issues:



Breast/ bottle feeding
SIDS prevention
Support for Mother
Adolescent issues:


Substance use (including tobacco) prevention
and treatment
Safe sex advice
Other interventions?